A 3-year-old with intermittent exotropia shows marked overelevation of the adducting eye in lateral gaze and a V pattern exceeding 25 prism diopters between upgaze and downgaze. Fundus examination shows extorsion. The most appropriate surgical plan addresses which structure?

• A Bilateral superior oblique tucking
• B Bilateral superior rectus recession alone
• C Bilateral lateral rectus resection
• D Graded recession or anterior transposition of the overacting inferior obliques ✓

Explanation

Overelevation in adduction with a V pattern and fundus extorsion is the classic picture of bilateral inferior oblique overaction, commonly accompanying infantile strabismus. Weakening the inferior obliques by graded recession, myectomy or anterior transposition flattens the V pattern and reduces the vertical incomitance. Superior oblique tucking would worsen the V pattern, and horizontal surgery alone leaves the oblique dysfunction untouched.

Reference: Khurana Comprehensive Ophthalmology, 8th ed.

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Written and medically reviewed by the StethoPrep medical team.